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Jonathan B Perlin

Publications and source records attributed to Jonathan B Perlin.

16 recordsLinked to original sources
PubMed2006

Improving performance through knowledge translation in the Veterans Health Administration.

The Veterans Health Administration (VA) provides a case study for linking performance measurement, information technology, and aligned research efforts to facilitate quality improvement in a large, complex health system. Dialogue between clinical researchers and VA leaders occurs through structured activities (e.g., the Quality Enhancement Research Initiative); engagement with formal policymaking bodies (e.g., development of clinical guidelines and performance measures); and informally through local, regional, and national work groups responsible for implementing evidence-based clinical initiatives. Important lessons for knowledge translation from the VA experience include the following: research needs to generate clinical evidence relevant to the needs of patients served by the health system; researchers need to systematically study the process of evidence implementation itself to increase the capability of the health system to improve performance; although print and Web-based dissemination structures are important, direct accessibility of researchers to policymakers and clinical leaders through formal and informal mechanisms is key; and both top-down and bottom-up activities are needed to integrate evidence-based practice across a large health system. As VA care moves from hospital and clinic into community-based settings and faces a new veteran population with different needs and expectations, knowledge-translation activities must develop new forms of evidence and more direct interaction with veterans and their caregivers.

Education, Continuing↗
PubMed2006

Reinventing Veterans Health Administration: focus on primary care.

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered.

Health Services Accessibility↗
PubMed2005

Quality of ambulatory care for women and men in the Veterans Affairs Health Care System.

BACKGROUND: Gender differences in inpatient quality of care are well known. However, whether men and women receive equivalent ambulatory care is less well understood. OBJECTIVE: To study gender differences in quality of care for patients receiving primary care in the Veterans Affairs (VA) Health Care System. DESIGN: Cross-sectional samples of VA enrollees during fiscal years 1999 to 2000. PARTICIPANTS: Samples of 6,442 to 86,405 men and women treated at VA facilities for whom at least 1 of 9 quality measures was available. MEASUREMENTS: Appropriate general preventive services (pneumococcal vaccination, influenza vaccination, colorectal cancer screening), and specific services for diabetes (annual hemoglobin A1c [HbA1c] testing, good glycemic control, annual diabetic eye exam), hypertension (good blood pressure control), or prior myocardial infarction (use of beta-blockers or aspirin). RESULTS: In adjusted analyses, there were no substantial gender differences in rates of appropriate care. For women compared with men, the adjusted relative risk for appropriate care ranged from 0.96 for blood pressure control (95% confidence interval: 0.93 to 0.99; P=.02) to 1.05 for HbA1c< or =8.0% (95% confidence interval: 1.03 to 1.07; P<.01). Analyses stratified by age demonstrated equivalent care between men and women in 9 of the 14 subgroups evaluated. CONCLUSIONS: In this large national health care system that predominantly serves men, the quality of ambulatory care is equivalent for women and men on numerous measures.

Ambulatory Care↗
PubMed2004

Differences in health-related quality of life in rural and urban veterans.

OBJECTIVES: We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. METHODS: We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. RESULTS: Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. CONCLUSIONS: When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.

Chi-Square Distribution↗
PubMed2004

The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care.

The Veterans Health Administration is the United States' largest integrated health system. Once disparaged as a bureaucracy providing mediocre care, the Department of Veterans Affairs (VA) reinvented itself during the past decade through a policy shift mandating structural and organizational change, rationalization of resource allocation, explicit measurement and accountability for quality and value, and development of an information infrastructure supporting the needs of patients, clinicians, and administrators. Today, the VA is recognized for leadership in clinical informatics and performance improvement, cares for more patients with proportionally fewer resources, and sets national benchmarks in patient satisfaction and for 18 indicators of quality in disease prevention and treatment.

Delivery of Health Care, Integrated↗
PubMed2003

Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.

BACKGROUND: In the mid-1990s, the Department of Veterans Affairs (VA) health care system initiated a systemwide reengineering to, among other things, improve its quality of care. We sought to determine the subsequent change in the quality of health care and to compare the quality with that of the Medicare fee-for-service program. METHODS: Using data from an ongoing performance-evaluation program in the VA, we evaluated the quality of preventive, acute, and chronic care. We assessed the change in quality-of-care indicators from 1994 (before reengineering) through 2000 and compared the quality of care with that afforded by the Medicare fee-for-service system, using the same indicators of quality. RESULTS: In fiscal year 2000, throughout the VA system, the percentage of patients receiving appropriate care was 90 percent or greater for 9 of 17 quality-of-care indicators and exceeded 70 percent for 13 of 17 indicators. There were statistically significant improvements in quality from 1994-1995 through 2000 for all nine indicators that were collected in all years. As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators. CONCLUSIONS: The quality of care in the VA health care system substantially improved after the implementation of a systemwide reengineering and, during the period from 1997 through 2000, was significantly better than that in the Medicare fee-for-service program. These data suggest that the quality-improvement initiatives adopted by the VA in the mid-1990s were effective.

Fee-for-Service Plans↗
PubMed2003

Variation in mortality risk factors with time after coronary artery bypass graft operation.

BACKGROUND: Differences in mortality risk factor sets during different time periods (eg, short-term versus intermediate-term) after coronary artery bypass grafting have been reported. However, little is known about the time-varying effects of mortality risk factors after the operation. METHODS: We analyzed 11,815 veterans who had coronary artery bypass grafting at any of the 43 Veterans Affairs cardiac surgery centers from October 1997 to September 1999. Time-varying effects of 14 mortality risk factors during the 210 days after coronary artery bypass grafting were evaluated using Cox B-spline regression, which provides an estimate of risk for each variable for each day after operation. RESULTS: Eight variables showed significant time-varying effects after operation. The effect of prior heart operation was very high immediately after operation, but disappeared within 1 week. Three other cardiac variables (prior myocardial infarction, preoperative intraaortic balloon pump, and Canadian Cardiovascular Society anginal class III or IV) also conferred the highest risk on the day of operation and decreased thereafter. In contrast, the four time-varying noncardiac risk variables (age, impaired functional status, chronic obstructive pulmonary disease, and renal dysfunction) showed little or no association with mortality immediately after operation, but had increasing impact during the several months after operation. CONCLUSIONS: A sizable number of mortality risk factors have time-varying effects after coronary artery bypass grafting. Several cardiac risk factors have peak impact immediately after operation but dissipate thereafter. Several noncardiac risk factors confer little risk immediately after operation, but these risks increase during several months. This information may help clinicians focus management strategies for patients during the 7 months after operation.

Age Factors↗
PubMed2002

Receipt of nutrition and exercise counseling among medical outpatients with psychiatric and substance use disorders.

OBJECTIVE: Mentally ill persons represent a population that is potentially vulnerable to receiving a poorer quality of medical care. This study examines the relationship between mental disorders and the likelihood of receiving recommended nutrition and exercise counseling. DESIGN: Cross-sectional study combining chart-review data and administrative database records. SETTING: One hundred forty-seven Veterans Affairs (VA) medical centers nationwide. PATIENTS/PARTICIPANTS: The sample included 90,240 patients with obesity and/or hypertension who had >/=3 medical outpatient visits in the previous year. MEASUREMENTS AND MAIN RESULTS: The outcomes of interest were chart-documented receipt of nutrition counseling and receipt of exercise counseling in the past 2 years. This chart information was merged with VA inpatient and outpatient administrative databases, which were used to identify persons with diagnosed mental disorders. Most patients received nutrition counseling (90.4%), exercise counseling (88.5%), and counseling for both (85.7%) in the past 2 years. The rates of counseling differed significantly but modestly by mental health status. The lowest rates were found among patients dually diagnosed with comorbid psychiatric and substance use disorders; however, the magnitude of the disparities was small, ranging from 2% to 4% across outcomes. These results were unchanged after controlling for demographics, health status, and facility characteristics using multivariable generalized estimating equation modeling. CONCLUSIONS: Among patients engaged in active medical treatment, rates of nutrition and exercise counseling were high at VA medical centers, and the diagnosis of mental illness was not a substantial barrier to such counseling. More work is needed to determine whether these findings generalize to non-VA settings and to understand the potential role that integrated systems such as the VA can play in reducing disparities for vulnerable populations.

Aged↗
PubMed2002

Quality of preventive medical care for patients with mental disorders.

BACKGROUND/OBJECTIVES: This study compares quality of preventive services between persons with and without mental/substance use disorders for a national sample of medical outpatients. RESEARCH DESIGN: Cross-sectional study. SUBJECTS: A total of 113,505 veterans with chronic conditions and at least three general medical visits to Veterans Health Administration medical providers during 1998 to 1999. MEASURES: Chart-derived rates of eight preventive services: two measures of immunization, four measures of cancer screening, and two of tobacco screening and counseling. Multivariable-generalized estimating equations compared rates of each preventive service among veterans with psychiatric disorders, substance use disorders, both, and neither, adjusting for demographic, health status, and facility-level characteristics. RESULTS: On average, persons in the sample obtained 64% of the eight preventive procedures for which they were eligible. Overall rates of currency with preventive services were 58% for patients with combined psychiatric/substance use disorders, 60% and 65% for those with psychiatric and substance use disorders alone, and 66% for those with neither psychiatric nor substance use disorders. Each difference remained statistically significant in multivariable models. CONCLUSIONS: In this sample of patients in active medical treatment, rates of preventive services were higher than rates reported for population-based, private-sector samples. Despite these high-baseline rates, persons with psychiatric disorders, particularly with comorbid substance use, were at risk for lower rate of receipt of preventive services.

Chi-Square Distribution↗
PubMed2002

Mental disorders and quality of diabetes care in the veterans health administration.

OBJECTIVE: The population of persons with mental disorders is potentially vulnerable to poor quality of medical care. This study examined the relationship between mental disorders and quality of diabetes care in a national sample of veterans. METHOD: Chart-abstracted quality data were merged with outpatient and inpatient administrative database records for a sample of veterans with diabetes who had at least three outpatient visits in the previous year (N=38,020). Mental health diagnoses were identified by use of the administrative data. Quality of diabetes care was assessed with five indicators by chart documentation: annual foot inspection, pedal pulses examination, foot sensory examination, retina examination, and glycated hemoglobin determination. RESULTS: Approximately a quarter of the sample had a diagnosed mental disorder (23.7% with psychiatric disorder only, 1.3% with substance use disorder only, and 2.6% with a dual diagnosis). Overall rates of receipt for the indicators were higher than national benchmarks for all patient subgroups, ranging from 70.8% for retina examination to 95.0% for foot inspection. Rates for both retina examination and foot sensory examination differed significantly by mental health status, mainly because of lower rates among those with a substance use disorder. The associations remained significant in multivariate generalized estimating equation analyses that controlled for demographic characteristics, health status, use of medical services, and hospital-level characteristics. CONCLUSIONS: Rates for secondary prevention of diabetes were remarkably high at Department of Veterans Affairs medical centers, although patients with mental disorders (particularly substance use disorders) were somewhat less likely to receive some of the recommended interventions.

Aged↗
PubMedDate not supplied

Reinventing Veterans Health Administration: focus on primary care.

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered. The Veterans Health Administration (VHA) is an integrated healthcare system that has implemented change to improve primary care access to the veterans it serves, while not only maintaining but also actually improving the quality of care. Many healthcare executives are struggling with achieving desirable access to care and continuity of care. To confront this problem, many large and small practices have initiated an approach known as advanced clinic access, open access, or same-day scheduling, introduced by the Institute for Healthcare Improvement (IHI). This approach has increasingly been used to reduce waits and delays in primary care without adding resources. To measure quality of care, specific performance measures were developed to quantify the effectiveness of primary care in VHA. Although it was initially viewed with concern and suspicion and was seen as a symptom of unnecessary micromanagement, healthcare team members were encouraged to use performance feedback as an opportunity for systems improvement as well as self-assessment and performance improvement for the team. All quality data are posted quarterly on VHA's internal web site, providing visible accountability at all levels of the organization. Clinical workflow redesign leads to reduced wait times without compromising quality of care. These large system improvements are applicable to large and small organizations looking to tackle change through the use of a collaborative model.

Delivery of Health Care↗